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Arafa A, Negida A, Elsheikh M, Emadeldin M, Hegazi H, Senosy S. Defensive medicine practices as a result of malpractice claims and workplace physical violence: a cross-sectional study from Egypt. Sci Rep 2023; 13:22371. [PMID: 38102200 PMCID: PMC10724153 DOI: 10.1038/s41598-023-47720-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
Defensive medicine refers to practices motivated mainly by legal rather than medical purposes. Increased healthcare costs, overutilization of medical services, and potential harm to patients from unnecessary procedures are among its drawbacks. We performed this study to assess the prevalence of defensive medicine practices in Egypt and their associations with experiencing malpractice claims and workplace physical violence. We investigated 1797 physicians (68.1% male), with an average age of 36.8 ± 9.1 years, practicing in Egypt between January 14th and February 23rd, 2023. SPSS was used for statistical analysis. The majority reported engaging in defensive medicine practices. Specifically, 89.6% acknowledged avoiding high-risk procedures, 87.8% refrained from treating high-risk patients, 86.8% admitted to making unnecessary referrals, 84.9% acknowledged ordering unnecessary tests, 61.4% reported performing unnecessary procedures, and 56.4% disclosed prescribing unnecessary medications. Obstetricians and surgeons exhibited the highest rates of defensive medicine. Using linear regression analysis adjusted for age and sex, malpractice claims and workplace physical violence were associated with defensive medicine score (zero-100): βs (95% CIs) = 5.05 (3.10, 6.99) and 5.60 (3.50, 7.71), respectively, (p values < 0.001). In conclusion, defensive medicine is deeply ingrained in the clinical routines of Egyptian physicians. Establishing a comprehensive national medical liability framework is required.
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Affiliation(s)
- Ahmed Arafa
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt.
| | - Ahmed Negida
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Elsheikh
- Department of Health Informatics, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
- Department of Emergency Medicine and Traumatology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mohamed Emadeldin
- Department of Urology, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Hesham Hegazi
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
| | - Shaimaa Senosy
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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Zheng J, Lu Y, Li W, Zhu B, Yang F, Shen J. Prevalence and determinants of defensive medicine among physicians: a systematic review and meta-analysis. Int J Qual Health Care 2023; 35:mzad096. [PMID: 38060672 DOI: 10.1093/intqhc/mzad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/12/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
Defensive medicine, characterized by physicians' inclination toward excessive diagnostic tests and procedures, has emerged as a significant concern in modern healthcare due to its high prevalence and detrimental effects. Despite the growing concerns among healthcare providers, policymakers, and physicians, comprehensive synthesis of the literature on the prevalence and determinants of defensive medicine among physicians has yet been reported. A comprehensive literature search was conducted to identify eligible studies published between 1 January 2000 and 31 December 2022, utilizing six databases (i.e. Web of Science, PubMed, Embase, Scopus, PsycINFO, and Cochrane Library). A meta-analysis was conducted to determine the prevalence and determinants of defensive medicine. Of the 8892 identified articles, 64 eligible studies involving 35.9 thousand physicians across 23 countries were included. The overall pooled prevalence of defense medications was 75.8%. Physicians engaged in both assurance and avoidance behaviors, with the most prevalent subitems being increasing follow-up and avoidance of high-complication treatment protocols. The prevalence of defensive medicine was higher in the African region [88.1%; 95% confidence interval (CI): 80.4%-95.8%] and lower-middle-income countries (89.0%; 95% CI: 78.2%-99.8%). Among the medical specialties, anesthesiologists (92.2%; 95% CI: 89.2%-95.3%) exhibited the highest prevalence. Further, the pooled odds ratios (ORs) of the nine factors at the individual, relational, and organizational levels were calculated, and the influence of previous experience in medical-legal litigation (OR: 1.65; 95% CI: 1.13-2.18) should be considered. The results of this study indicate a high global prevalence of defensive medicine among physicians, underscoring the necessity of implementing targeted interventions to reduce its use, especially in certain regions and specialties. Policymakers should implement measures to improve physicians' medical skills, enhance physician-patient communication, address physicians' medical-legal litigation fears, and reform the medical liability system. Future research should focus on devising and assessing interventions to reduce the use of defensive medicine and to improve the quality of patient care.
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Affiliation(s)
- Junyao Zheng
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Yongbo Lu
- School of Public Policy and Administration, Xi'an Jiaotong University, 28 West Xianning Road, Xi'an 710049, China
| | - Wenjie Li
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
| | - Bin Zhu
- School of Public Health and Emergency Management, Southern University of Science and Technology, 1008 Xueyuan Road, Shenzhen, Guangdong 518005, China
| | - Fan Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai, 200030 China
- China Institute for Urban Governance, Shanghai Jiao Tong University, 1954 Huashan Road, Shanghai 200030, China
| | - Jie Shen
- Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 Yishan Road, Shanghai 200030, China
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Al-Balas Q, Altawalbeh S, Rinaldi C, Ibrahim I. The practice of defensive medicine among Jordanian physicians: A cross sectional study. PLoS One 2023; 18:e0289360. [PMID: 37943831 PMCID: PMC10635536 DOI: 10.1371/journal.pone.0289360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 07/18/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Defensive medicine (DM) is a deviation from medical practice that is induced primarily by a threat of liability. While the DM behavior is well studied in the developed countries, little is known in developing countries and never been evaluated in Jordan. OBJECTIVE To evaluate the prevalence of DM practice in Jordan among physicians and to investigate reasons behind its practice and potential strategies to alleviate this practice. METHODS In this Cross-sectional study, self-administered questionnaire was distributed to a sample of physicians in both public and private sectors in Jordan. The collection period was from Jan 2021 to June 2021. The prevalence of DM practice was estimated among the study sample. Frequency scores of different DM behaviors, reasons of DM behaviors, and effectiveness of strategies in changing DM behaviors were summarized as average frequency scores with standard deviations. Multivariable linear regression models were conducted to evaluate potential predictors of total assurance and avoidance behavior scores. RESULTS A total of 175 Jordanian physicians completed the survey. The prevalence of adopting (or witnessing) DM behaviors among the study sample was 68% (n = 119). Diagnostic laboratory exams followed by prescribed medications were the most practiced behaviors in excessive rate during a typical working week. Unfavorable legislation for the physician was reported as the headmost reason for practicing DM, followed by pressure from the public and mass media opinion. Continuous update of knowledge, abilities, and performance and following specific protocols and/or appropriate clinical evidence and appropriate multidisciplinary and multi-professional communication were the most effective strategies that can mitigate DM behaviors. CONCLUSIONS Defensive medicine practice is common among Jordanian physicians with concerns about increasing pattern in the future.
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Affiliation(s)
- Qosay Al-Balas
- Department of Medicinal Chemistry and Pharmacognosy, Faculty of Pharmacy, Jordan University of Science & Technology, Irbid, Jordan
| | - Shoroq Altawalbeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Carmela Rinaldi
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Learning and Research Area, AOU Maggiore Della Carità, Novara, Italy
| | - Ibtihal Ibrahim
- Department of Pharmacy, Faculty of Pharmacy, Al-Zaytoonah University of Jordan, Amman, Jordan
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Kakemam E, Arab-Zozani M, Raeissi P, Albelbeisi AH. The occurrence, types, reasons, and mitigation strategies of defensive medicine among physicians: a scoping review. BMC Health Serv Res 2022; 22:800. [PMID: 35725449 PMCID: PMC9210603 DOI: 10.1186/s12913-022-08194-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Defensive Medicine (DM) concept refers to all medical care provided by physicians without increasing the benefits to the patient, the primary purpose of which is to prevent the risk of litigation. Although several studies have been published investigating the occurrence of DM around the world, no review conducted on DM among physicians. Therefore, this study aims to summarize and map the available evidence on occurrence, types of behaviors, and reasons for practicing of DM among physicians and possible solutions and strategies to reduce DM in the literature. Methods This is a scoping review in which we searched Web of Science, Scopus, and PubMed in December 2021. Our target was original studies of any type that included data on DM among physicians between 2000 and 2021. We followed the JBI guideline for conducting a scoping review and for increasing the rigor of the study. First, the percentage was used to summarize the occurrence of DM, and then, findings related to types of behaviors and reasons for practicing DM and mitigation strategies were analyzed inductively in NVivo 10 in three stages. Results Twenty-seven studies were included in the review. The overall occurrence of DM practice ranged from 6.7 to 99.8%. Two types of DM behaviors including assurance and avoidance behaviors have been identified. The common reasons for practicing DM were categorized into four themes, patient-related reasons, physician-related reasons, organization-related reasons, and society-related reasons. The main strategies to prevent or reduce DM are structured training and education, restoring physician-patient relationships, reform of the health system, and reform of the liability system. Conclusions The vast majority of research studies were conducted in high-income countries, and studies are needed to measure this phenomenon and its consequences in depth in low- and middle-income countries. Various solutions and strategies are needed to reduce defensive behaviors such as structured training and education, restoring physician-patient relationships, reforming the health system, and reforming the liability system. Keywords Defensive medicine, Defensive practice, Medical malpractice, Physicians, Scoping review Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08194-w.
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Affiliation(s)
- Edris Kakemam
- Clinical Research Development Unit of Tabriz Valiasr Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Pouran Raeissi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Baungaard N, Skovvang PL, Assing Hvidt E, Gerbild H, Kirstine Andersen M, Lykkegaard J. How defensive medicine is defined in European medical literature: a systematic review. BMJ Open 2022; 12:e057169. [PMID: 35058268 PMCID: PMC8783809 DOI: 10.1136/bmjopen-2021-057169] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 12/13/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Defensive medicine has originally been defined as motivated by fear of malpractice litigation. However, the term is frequently used in Europe where most countries have a no-fault malpractice system. The objectives of this systematic review were to explore the definition of the term 'defensive medicine' in European original medical literature and to identify the motives stated therein. DESIGN Systematic review. DATA SOURCES PubMed, Embase and Cochrane, 3 February 2020, with an updated search on 6 March 2021. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we reviewed all European original peer-reviewed studies fully or partially investigating 'defensive medicine'. RESULTS We identified a total of 50 studies. First, we divided these into two categories: the first category consisting of studies defining defensive medicine by using a narrow definition and the second category comprising studies in which defensive medicine was defined using a broad definition. In 23 of the studies(46%), defensive medicine was defined narrowly as: health professionals' deviation from sound medical practice motivated by a wish to reduce exposure to malpractice litigation. In 27 studies (54%), a broad definition was applied adding … or other self-protective motives. These self-protective motives, different from fear of malpractice litigation, were grouped into four categories: fear of patient dissatisfaction, fear of overlooking a severe diagnosis, fear of negative publicity and unconscious defensive medicine. Studies applying the narrow and broad definitions of defensive medicine did not differ regarding publication year, country, medical specialty, research quality or number of citations. CONCLUSIONS In European research, the narrow definition of defensive medicine as exclusively motivated by fear of litigation is often broadened to include other self-protective motives. In order to compare results pertaining to defensive medicine across countries, future studies are recommended to specify whether they are using the narrow or broad definition of defensive medicine. PROSPERO REGISTRATION NUMBER CRD42020167215.
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Affiliation(s)
- Nathalie Baungaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Pia Ladeby Skovvang
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Elisabeth Assing Hvidt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Department for the Study of Culture, University of Southern Denmark, Odense, Denmark
| | - Helle Gerbild
- Health Sciences Research Centre, UCL University College, Odense, Denmark
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Merethe Kirstine Andersen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jesper Lykkegaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Abstract
AIM Defensive medicine refers to practices with low marginal benefit to patients that doctors may undertake to protect themselves from legal liability. We aimed to develop a scale to measure the practice of defensive medicine. METHOD We identified aspects of defensive medicine previously reported in the literature and conducted and analyzed semi-structured interviews with 21 physicians in Sakarya to augment and clarify these aspects between May 15, 2018, and June 15, 2018. Informed by these results, we developed, pilot tested, refined, and fielded a 10-item survey to 1724 doctors in Turkey between April 1, 2019, and July 16, 2019. We examined the psychometric properties of the scale using exploratory (EFA) and confirmatory factor analyses (CFA). RESULTS The 10-item scale provided measures of 2 factors: positive defensive medicine (assurance) and negative defensive medicine (avoidance), with Cronbach's alpha >0.8 for the scale and both subscales in both the EFA and CFA subsamples and excellent goodness-of-fit measures. CONCLUSIONS We developed a highly reliable scale to measure positive and negative defensive medicine practice that may be suitable for future research on physician decision making.
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Affiliation(s)
- Özgün Ünal
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
| | - Mahmut Akbolat
- Department of Healthcare Management, Business Faculty, Sakarya University, Sakarya, Turkey
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Physicians' views and experiences of defensive medicine: An international review of empirical research. Health Policy 2021; 125:634-642. [PMID: 33676778 DOI: 10.1016/j.healthpol.2021.02.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022]
Abstract
This study systematically maps empirical research on physicians' views and experiences of hedging-type defensive medicine, which involves providing services (eg, tests, referrals) to reduce perceived legal risks. Such practices drive over-treatment and low value healthcare. Data sources were empirical, English-language publications in health, legal and multi-disciplinary databases. The extraction framework covered: where and when the research was conducted; what methods of data collection were used; who the study participants were; and what were the study aims, main findings in relation to hedging-type defensive practices, and proposed solutions. 79 papers met inclusion criteria. Defensive medicine has mainly been studied in the United States and European countries using quantitative surveys. Surgery and obstetrics have been key fields of investigation. Hedging-type practices were commonly reported, including: ordering unnecessary tests, treatments and referrals; suggesting invasive procedures against professional judgment; ordering hospitalisation or delaying discharge; and excessive documentation in medical records. Defensive practice was often framed around the threat of negligence lawsuits, but studies recognised other legal risks, including patient complaints and regulatory investigations. Potential solutions to defensive medicine were identified at macro (law, policy), meso (organisation, profession) and micro (physician) levels. Areas for future research include qualitative studies to investigate the behavioural drivers of defensive medicine and intervention research to determine policies and practices that work to support clinicians in de-implementing defensive, low-value care.
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Kherad O, Peiffer-Smadja N, Karlafti L, Lember M, Aerde NV, Gunnarsson O, Baicus C, Vieira MB, Vaz-Carneiro A, Brucato A, Lazurova I, Leśniak W, Hanslik T, Hewitt S, Papanicolaou E, Boeva O, Dicker D, Ivanovska B, Yldiz P, Lacor P, Cranston M, Weidanz F, Costantino G, Montano N. The challenge of implementing Less is More medicine: A European perspective. Eur J Intern Med 2020; 76:1-7. [PMID: 32303454 DOI: 10.1016/j.ejim.2020.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/12/2020] [Accepted: 04/04/2020] [Indexed: 01/05/2023]
Abstract
The concept of Less is More medicine emerged in North America in 2010. It aims to serve as an invitation to recognize the potential risks of overuse of medical care that may result in harm rather than in better health, tackling the erroneous assumption that more care is always better. In response, several medical societies across the world launched quality-driven campaigns ("Choosing Wisely") and published "top-five lists" of low-value medical interventions that should be used to help make wise decisions in each clinical domain, by engaging patients in conversations about unnecessary tests, treatments and procedures. However, barriers and challenges for the implementation of Less is More medicine have been identified in several European countries, where overuse is rooted in the culture and demanded by a society that requests certainty at almost any cost. Patients' high expectations, physician's behavior, lack of monitoring and pernicious financial incentives have all indirect negative consequences for medical overuse. Multiple interventions and quality-measurement efforts are necessary to widely implement Less is More recommendations. These also consist of a top-five list of actions: (1) a novel cultural approach starting from medical graduation courses, up to (2) patient and society education, (3) physician behavior change with data feedback, (4) communication training and (5) policy maker interventions. In contrast with the prevailing maximization of care, the optimization of care promoted by Less is More medicine can be an intellectual challenge but also a real opportunity to promote sustainable medicine. This project will constitute part of the future agenda of the European Federation of Internal Medicine.
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Affiliation(s)
- Omar Kherad
- Department of Internal Medicine, La Tour Hospital and University of Geneva, Geneva, Switzerland.
| | - Nathan Peiffer-Smadja
- Assistance Publique - Hôpitaux de Paris, Hôpital Bichat-Claude Bernard, Paris, France
| | - Lina Karlafti
- 1st Proedeutic Internal Medicine Clinic, AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Greece
| | - Margus Lember
- Department of Internal Medicine, University of Tartu and University Hospital, Tartu, Estonia
| | - Nathalie Van Aerde
- Invited member of the Belgian Society of Internal Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Orvar Gunnarsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Cristian Baicus
- Department of Internal Medicine, Carol Davila University of Medicine and Pharmacy, Colentina University Hospital, Bucharest, Romania
| | - Miguel Bigotte Vieira
- Serviço de Nefrologia, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - António Vaz-Carneiro
- Centro de Estudos de Medicina Baseados na Evidência, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa, Portugal; Cochrane Portugal, Lisboa, Portugal
| | - Antonio Brucato
- Department of Biomedical and Clinical Sciences, University of Milan, Fatebenefratelli Hospital, Milan, Italy
| | - Ivica Lazurova
- PJ Safarik University I. Internal Clinic, Kosice, Slovakia
| | - Wiktoria Leśniak
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Thomas Hanslik
- Assistance Publique - Hôpitaux de Paris, Hôpital Ambroise Paré, Paris, France
| | - Stephen Hewitt
- Medical Division, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Norway
| | | | - Olga Boeva
- Imaging Department, Stavropol State Medical University and Stavropol Territory Hospital, Russian Federation
| | - Dror Dicker
- Department of Internal Medicine, Rabin Medical Center, Petah Tikva, Israel
| | - Biljana Ivanovska
- Private Health Organization, Office of Internal Medicine, Skopje, Macedonia
| | - Pinar Yldiz
- Department of Internal Medicine İstanbul, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - Patrick Lacor
- Department of Internal Medicine and Infectiology, Universitair Ziekenhuis, Brussel, Belgium
| | - Mark Cranston
- MBBS Hinchingbrooke Hospital, Huntingdon, United Kingdom
| | | | - Giorgio Costantino
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - Nicola Montano
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, and Department of Clinical Science and Community Health, University of Milan, Milan, Italy.
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Garattini L, Padula A. Defensive medicine in Europe: a 'full circle'? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:477-482. [PMID: 31919702 DOI: 10.1007/s10198-019-01151-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy.
| | - Anna Padula
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy
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10
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Garattini L, Padula A. Defensive medicine in Europe: a 'full circle'? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:165-170. [PMID: 31879861 DOI: 10.1007/s10198-019-01144-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 12/03/2019] [Indexed: 05/24/2023]
Affiliation(s)
- Livio Garattini
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy.
| | - Anna Padula
- CESAV, Centre for Health Economics, Institute for Pharmacological Research Mario Negri IRCCS, 24020, Ranica, Italy
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Albolino S, Bellandi T, Cappelletti S, Di Paolo M, Fineschi V, Frati P, Offidani C, Tanzini M, Tartaglia R, Turillazzi E. New Rules on Patient's Safety and Professional Liability for the Italian Health Service. Curr Pharm Biotechnol 2020; 20:615-624. [PMID: 30961486 DOI: 10.2174/1389201020666190408094016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The phenomenon of clinical negligence claims has rapidly spread to United States, Canada and Europe assuming the dimensions and the severity of a pandemia. Consequently, the issues related to medical malpractice need to be studied from a transnational perspective since they raise similar problems in different legal systems. METHODS Over the last two decades, medical liability has become a prominent issue in healthcare policy and a major concern for healthcare economics in Italy. The failures of the liability system and the high cost of healthcare have led to considerable legislative activity concerning medical malpractice liability, and a law was enacted in 2012 (Law no. 189/2012), known as the "Balduzzi Law". RESULTS The law tackles the mounting concern over litigation related to medical malpractice and calls for Italian physicians to follow guidelines. Briefly, the law provided for the decriminalisation of simple negligence of a physician on condition that he/she followed the guidelines and "good medical practice" while carrying out his/her duties, whilst the obligation for compensation, as defined by the Italian Civil Code, remained. Judges had to consider that the physician followed the provisions of the guidelines but nevertheless caused injury to the patient. CONCLUSION However, since the emission of the law, thorny questions remain which have attracted renewed interest and criticism both in the Italian courts and legal literature. Since then, several bills have been presented on the topic and these have been merged into a single text entitled "Regulations for healthcare and patient safety and for the professional responsibility of healthcare providers".
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Affiliation(s)
- Sara Albolino
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Tommaso Bellandi
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Simone Cappelletti
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Di Paolo
- Section of Legal Medicine, Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Italy
| | - Caterina Offidani
- Unit of Legal Medicine, Bambino Gesu Children's Hospital, IRCCS, P.za Sant'Onofrio 4, Rome, Italy
| | - Michela Tanzini
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Riccardo Tartaglia
- Regional Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Emanuela Turillazzi
- Section of Legal Medicine, Department of Surgical Pathology, Medical, Molecular and Critical Area, University of Pisa, Pisa, Italy
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12
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Di Paolo M, Gori F, Papi L, Turillazzi E. A review and analysis of new Italian law 219/2017: 'provisions for informed consent and advance directives treatment'. BMC Med Ethics 2019; 20:17. [PMID: 30832644 PMCID: PMC6399822 DOI: 10.1186/s12910-019-0353-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 02/21/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND In December 2017, Law 219/2017, 'Provisions for informed consent and advance directives', was approved in Italy. The law is the culmination of a year-long process and the subject of heated debate throughout Italian society. Contentious issues (advance directives, the possibility to refuse medical treatment, the withdrawal of medical treatment, nutrition and hydration) are addressed in the law. MAIN TEXT What emerges clearly are concepts such as quality of life, autonomy, and the right to accept or refuse any medical treatment - concepts that should be part of an optimal relationship between the patient and healthcare professionals. The law maximizes the value of the patient's time to decide. Every patient is allowed to make choices for the present (consenting to or refusing current treatment) as well as for the future, conceived as a continuation of the present, and to decide what comes next, based on what he/she already knows. The law identifies three distinct but converging paths towards the affirmation of a care relationship based on reciprocal trust and respect: the possibility to consent to or refuse treatment, the shared care planning, and advance directives. CONCLUSIONS The fundamental point to emerge from the new Italian law is that consensus is an essential connotation of the treatment relationship. Consensus is not limited to the acceptance/rejection of medical treatment but is ongoing. It is projected into the future through shared care planning and advance directives which act as tools for self-determination and the manifestation of the beliefs and preferences of persons unable to express their will. These principles are in line with the idea of appropriate care as evaluated from two different perspectives, one of scientific adequacy and the other commensurate with the individual's resources, fragility, values, and beliefs. Surely, however, the new law is not the end of the matter on issues such as conscientious objection, which is deeply rooted within the Italian cultural and political debate. In this regard, healthcare institutions and policymakers will be called upon to develop and implement organizational policies aimed at the management of foreseeable conscientious objection in this field.
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Affiliation(s)
- Marco Di Paolo
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126 Pisa, Italy
| | - Federica Gori
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126 Pisa, Italy
| | - Luigi Papi
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126 Pisa, Italy
| | - Emanuela Turillazzi
- Section of Legal Medicine, Department of Clinical, Medical, Molecular Pathology and Critical Medicine, University of Pisa, Via Paolo Savi 57, 56126 Pisa, Italy
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Stasi E, Michielan A, Morreale GC, Tozzi A, Venezia L, Bortoluzzi F, Triossi O, Soncini M, Leandro G, Milazzo G, Anderloni A. Five common errors to avoid in clinical practice: the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) Choosing Wisely Campaign. Intern Emerg Med 2019; 14:301-308. [PMID: 30499071 DOI: 10.1007/s11739-018-1992-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/20/2018] [Indexed: 02/08/2023]
Abstract
Modern medicine provides almost infinite diagnostic and therapeutic possibilities if compared to the past. As a result, patients undergo a multiplication of tests and therapies, which in turn may trigger further tests, often based on physicians' attitudes or beliefs, which are not always evidence-based. The Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) adhered to the Choosing Wisely Campaign to promote an informed, evidence-based approach to gastroenterological problems. The aim of this article is to report the five recommendations of the AIGO Choosing Wisely Campaign, and the process used to develop them. The AIGO members' suggestions regarding inappropriate practices/interventions were collected. One hundred and twenty-one items were identified. Among these, five items were selected and five recommendations were developed. The five recommendations developed were: (1) Do not request a fecal occult blood test outside the colorectal cancer screening programme; (2) Do not repeat surveillance colonoscopy for polyps, after a quality colonoscopy, before the interval suggested by the gastroenterologist on the colonoscopy report, or based on the polyp histology report; (3) Do not repeat esophagogastroduodenoscopy in patients with reflux symptoms, with or without hiatal hernia, in the absence of different symptoms or alarm symptoms; (4) Do not repeat abdominal ultrasound in asymptomatic patients with small hepatic haemangiomas (diameter < 3 cm) once the diagnosis has been established conclusively; (5) Do not routinely prescribe proton pump inhibitors within the context of steroid use or long-term in patients with functional dyspepsia. AIGO adhered to the Choosing Wisely Campaign and developed five recommendations. Further studies are needed to assess the impact of these recommendations in clinical practice with regards to clinical outcome and cost-effectiveness.
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Affiliation(s)
- Elisa Stasi
- Gastroenterology Unit, National Institute of Gastroenterology "S. De Bellis" Research Hospital, Via Turi 27, 70013, Castellana Grotte, Ba, Italy.
| | - Andrea Michielan
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Santa Chiara, Trento, Italy
| | | | | | - Ludovica Venezia
- Gastroenterology Unit, AOU Città della Salute e della Scienza Turin, Turin, Italy
| | | | | | - Marco Soncini
- Gastroenterology Unit, San Carlo Borromeo Hospital, Milan, Italy
| | - Gioacchino Leandro
- Gastroenterology Unit, National Institute of Gastroenterology "S. De Bellis" Research Hospital, Via Turi 27, 70013, Castellana Grotte, Ba, Italy
| | - Giuseppe Milazzo
- Department of Medicine, Ospedale Vittorio Emanuele III, Salemi, Tp, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy
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Ionescu CA, Dimitriu M, Poenaru E, Bănacu M, Furău GO, Navolan D, Ples L. Defensive caesarean section: A reality and a recommended health care improvement for Romanian obstetrics. J Eval Clin Pract 2019; 25:111-116. [PMID: 30178624 PMCID: PMC6586009 DOI: 10.1111/jep.13025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/29/2018] [Accepted: 07/30/2018] [Indexed: 11/30/2022]
Abstract
RATIONALE Defensive caesarean section (CS) has become one of the most common medical procedure worldwide. Additionally, performing CS in accordance with the patient's choice is an appropriate professional practice. AIMS AND OBJECTIVE This paper reports a prospective, observational, multicenter study to quantify the use of this type of practice that is performed by obstetricians to avoid medico-legal complaints and decrease the frequency of malpractice litigations. METHODS We interviewed 73 obstetricians from three distinct units of obstetrics and gynaecology, to assess their opinion regarding defensive caesarean delivery and caesarean delivery performed upon maternal request. We conducted an opinion-based survey using questionnaires based on nine, close-ended questions. RESULTS Out of 73 respondents, 51 (69.9%) stated that they perform defensive CS; 63 (86.3%) declared that their choice of birth delivery is influenced by the risk of being accused of malpractice; 60 (82.2%) indicated that it is normal for the patient to be able to decide on the type of delivery; and 63 (86.3%) declared that they consult their patients regarding their delivery preferences. We found statistically significant differences between the respondents who declare that they perform defensive CS (69.9%) and those who said that they are influenced by the risk of malpractice when they choose the method of delivery for their patients (86.3%) (P < .001; McNemar Test). CONCLUSIONS The results of our study indicate that defensive caesarean section is a widespread practice among obstetrics practitioners in Romania.
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Affiliation(s)
- Cringu Antoniu Ionescu
- Department of Obstetrics and Gynecology “St Pantelimon” Clinical Emergency Hospital‘Carol Davila’ University of Medicine and PharmacyBucharestRomania
| | - Mihai Dimitriu
- Department of Obstetrics and Gynecology “St Pantelimon” Clinical Emergency Hospital‘Carol Davila’ University of Medicine and PharmacyBucharestRomania
| | - Elena Poenaru
- Complementary Sciences, Medical Informatics and Biostatistics Discipline“Carol Davila” University of Medicine and PharmacyBucharestRomania
| | - Mihai Bănacu
- Department of Obstetrics and GynecologyGynaecology “St Pantelimon” Clinical Emergency Hospital‘Carol Davila’ University of Medicine and PharmacyBucharestRomania
| | - Gheorghe Otto Furău
- Medicine Faculty, Department of Obstetrics and Gynecology, Emergency District HospitalWest UniversityAradRomania
| | - Dan Navolan
- Department of Obstetrics and Gynecology, City Emergency Clinical HospitalVictor Babes University of Medicine and Pharmacy TimisoaraRomania
| | - Liana Ples
- Department of Obstetrics and Gynecology “St Ioan” Clinical Emergency Hospital“Carol Davila” University of Medicine and PharmacyBucharestRomania
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Bryce AR, Rossi TA, Tansey C, Murphy RA, Murphy LA, Nakamura RK. Effect of client complaints on small animal veterinary internists. J Small Anim Pract 2018; 60:167-172. [PMID: 30284723 DOI: 10.1111/jsap.12936] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/30/2018] [Accepted: 07/03/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To investigate the effect of client complaints on small animal veterinary internists' welfare, job satisfaction and medical practices. MATERIALS AND METHODS Cross-sectional anonymous survey study. Between February 1 and March 31, 2017, a web-based questionnaire was made available through the American College Veterinary Internal Medicine sub-specialty Small Animal Internal Medicine E-mail List Serve. RESULTS A total of 92 completed surveys were available for review. Fifty-nine (64∙1%) respondents received a client complaint during the previous 6 months with cost of care the most common reason (53∙3%). Eighty-nine (96∙7%) respondents worry about client complaints being made against them with 33 (35∙8%) stating they worry "most of the time" or "all of the time." Thirty-two (34∙8%) reported being verbally assaulted by a client in the previous 6 months and 27 (29∙4%) reported being threatened with litigation during the previous 6 months. Sixty-six (71∙7%) have reported changing the way they practice medicine to avoid a client complaint and 40 (43∙5%) have considered changing their career because of complaints made against them. CLINICAL RELEVANCE Client complaints are a frequent problem among small animal veterinary internists that have detrimental effects on job satisfaction, psychological distress and medical practices.
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Affiliation(s)
- A R Bryce
- Department of Internal Medicine, Southern California Veterinary Specialty Hospital, Irvine, California 92614, USA
| | - T A Rossi
- Department of Internal Medicine, Southern California Veterinary Specialty Hospital, Irvine, California 92614, USA
| | - C Tansey
- Department of Oncology, Inland Valley Veterinary Specialists and Emergency Center, Upland, California 91786, USA
| | - R A Murphy
- Department of Psychiatry, Beamount Hospital, Dublin 9, Ireland
| | - L A Murphy
- Department of Critical Care, Veterinary Specialty Center of Delaware, New Castle, Delaware 19720, USA
| | - R K Nakamura
- Department of Cardiology, IDEXX Laboratories, Westbrook, Maine 04092, USA
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Hiyama T, Yoshihara M. Medical malpractice litigation pertaining to intestinal obstruction in Japan: 20-year review of civil court cases. COGENT MEDICINE 2018. [DOI: 10.1080/2331205x.2018.1529847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Toru Hiyama
- Health Service Center, Hiroshima University, 1-7-1 Kagamiyama, Higashihiroshima, Japan
| | - Masaharu Yoshihara
- Health Service Center, Hiroshima University, 1-7-1 Kagamiyama, Higashihiroshima, Japan
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Panella M, Rinaldi C, Leigheb F, Knesse S, Donnarumma C, Kul S, Vanhaecht K, Di Stanislao F. Prevalence and costs of defensive medicine: a national survey of Italian physicians. J Health Serv Res Policy 2017; 22:211-217. [PMID: 28534429 DOI: 10.1177/1355819617707224] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To identify the prevalence of the practice of defensive medicine among Italian hospital physicians, its costs and the reasons for practising defensive medicine and possible solutions to reduce the practice of defensive medicine. Methods Cross-sectional web survey. Main outcome measures Number of physicians reporting having engaged in any defensive medicine behaviour in the previous year. Results A total of 1313 physicians completed the survey. Ninety-five per cent believed that defensive medicine would increase in the near future. The practice of defensive medicine accounted for approximately 10% of total annual Italian national health expenditure. Conclusions Defensive medicine is a significant factor in health care costs without adding any benefit to patients. The economic burden of defensive medicine on health care systems should provide a substantial stimulus for a prompt review of this situation in a time of economic crisis. Malpractice reform, together with a systematic use of evidence-based clinical guidelines, is likely to be the most effective way to reduce defensive medicine.
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Affiliation(s)
- Massimiliano Panella
- 1 Associate Professor, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Carmela Rinaldi
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Fabrizio Leigheb
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Sanita Knesse
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Chiara Donnarumma
- 2 Research fellow, Department of Translational Medicine School of Medicine University of Eastern Piedmont, Novara, Italy
| | - Seval Kul
- 3 Associate Professor, School of Medicine, Department of Biostatistics, University of Gaziantep, Turkey
| | - Kris Vanhaecht
- 4 Assistant Professor, Leuven Institute for Healthcare Policy, KU Leuven, University of Leuven, Belgium
| | - Francesco Di Stanislao
- 5 Professor, Biomedical Sciences and Public Health, Universita' Politecnica delle Marche, Ancona, Italy
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The determinants of defensive medicine practices in Belgium. HEALTH ECONOMICS POLICY AND LAW 2016; 12:363-386. [PMID: 27873571 DOI: 10.1017/s174413311600030x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In 2010 the Belgian government introduced a low cost administrative procedure for compensating medical injuries to overcome the major shortcomings of the existing tort system. This paper examines, for the first time, to what extent this reform had an impact on physician specialists' defensive practices and what are the relevant determinants affecting physicians' clinical decision making. Based on a survey of 508 physicians, we find evidence of a relatively modest increase in defensive practices among physicians in various specialties. In general, 14% of the respondents, who were aware of the reform, reported to have increased their overall defensive behaviour, while respectively 18 and 13% altered their assurance and avoidance behaviour. Commonly used physician characteristics, such as claims experience and gender, have a similar impact on defensive medicine as documented in existing literature. Furthermore, the determinant physician's access to an incident reporting system is found to have a significant impact on most of the defensive medicine measures. Health care institutions may therefore play an important role in controlling and reducing physicians' defensive practices.
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Panella M, Rinaldi C, Leigheb F, Donnarumma C, Kul S, Vanhaecht K, Di Stanislao F. The determinants of defensive medicine in Italian hospitals: The impact of being a second victim. ACTA ACUST UNITED AC 2016; 31 Suppl 2:20-5. [PMID: 27373579 DOI: 10.1016/j.cali.2016.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Defensive medicine affects healthcare systems worldwide. The concerns and perception about medical liability could lead practitioners to practise defensive medicine. Second victim is a healthcare worker involved in an unanticipated adverse patient event. The role of being second victim and the other possible determinants for defensive medicine is mostly unclear. OBJECTIVE To study the condition of being second victim as a possible determinants of defensive medicine among Italian hospital physicians. DESIGN, SETTING AND PARTICIPANTS A secondary analysis of the database of the national survey study on the prevalence and the costs of defensive medicine in Italy that was carried out between April 2014 and June 2014 in 55 Italian hospitals was performed for this study. The demographic section of the questionnaire was selected including the physician's age, gender, specialty, activity volume, grade and the variable being a second victim after an adverse event. RESULTS A total sample of 1313 physicians (87.5% response rate) was used in the data analyses. Characteristics of the participants included a mean age 49.2 of years and 19.4 average years of experience. The most prominent predictor for practising defensive medicine was the physicians' experience of being a second victim after an adverse event (OR=1.88; 95%CI, 1.38-2.57). Other determinants included age, years of experience, activity volume and risk of specialty. CONCLUSIONS Malpractice reform, effective support to second victims in hospitals together with a systematic use of evidence-based clinical guidelines, emerged as possible recommendations for reducing defensive medicine.
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Affiliation(s)
- M Panella
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy
| | - C Rinaldi
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy.
| | - F Leigheb
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy
| | - C Donnarumma
- Department of Translational Medicine, School of Medicine, University of Eastern Piedmont, Novara, Italy
| | - S Kul
- Center for Applied Medical Statistics. University of Gaziantep, Gaziantep, Turkey
| | - K Vanhaecht
- Center for Health Services and Nursing Research, School of Public Health, University of Leuven, Leuven, Belgium
| | - F Di Stanislao
- Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
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Ali AA, Hummeida ME, Elhassan YAM, Nabag WOM, Ahmed MAA, Adam GK. Concept of defensive medicine and litigation among Sudanese doctors working in obstetrics and gynecology. BMC Med Ethics 2016; 17:12. [PMID: 26860084 PMCID: PMC4748468 DOI: 10.1186/s12910-016-0095-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 02/02/2016] [Indexed: 11/26/2022] Open
Abstract
Background Obstetrics and gynaecology always has reputation for being a highly litigious. The field of obstetrics and gynaecology is surrounded by different circumstances that stimulate the doctors to practice defensive medicine. Methods This study was directed to assess the extent and the possible effect of defensive medicine phenomenon (in term of knowledge and prevalence) on medical decision making among different grades of obstetric and gynaecologic Sudanese doctors, and to determine any experience of medical litigations with respect to sources and factors associated with it (in term of area of work, characteristics of the area at which the doctors worked, professionalism, hospitals systems…ect). Results A total of 117 doctors were approached, their distribution according to job description was as follow: consultants (42.7 %, 50\117) registrars (34.2 %, 40\117) and specialists (23.1 %, 27\117). The majority 89.7 % had the impression that litigation against doctors are increasing and 27.6 % had a direct experience of litigation. In this study less than one half (42.7 %) of the surveyed doctors knew the concept of defensive medicine and 71.8 % reported practicing one or another form of defensive medicine. The different sources of the litigations reported by the doctors included: maternal death (n = 15), perinatal death (n = 5), other {misdiagnosis, intra-uterine fetal death, uterine perforation, rupture uterus} (n = 4), fetal distress (n = 3), injury to viscera (n = 3) and shoulder dystocia (n = 2). In this study the experience of medical litigation was significantly observed among those who worked in area of blame culture (90.6 % Vs 56.5 %, P = 0.000). In logistic regression model, there was no significant difference between those who knew the concept of defence medicine and those who didn’t. Conclusion There should be strategic plan to reduce the practice of defensive medicine and medical litigation against doctors. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0095-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- AbdelAziem A Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kassala University, P.O. Box 496, Kassala, Sudan.
| | | | | | - Wisal O M Nabag
- Faculty of Medicine, Alzaiem Alazhari University, Al-ShaBiyya, Sudan
| | | | - Gamal K Adam
- Faculty of Medicine, Gadarif University, AlGadarif, Sudan
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Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician spending and subsequent risk of malpractice claims: observational study. BMJ 2015; 351:h5516. [PMID: 26538498 PMCID: PMC4633452 DOI: 10.1136/bmj.h5516] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
STUDY QUESTION Is a higher use of resources by physicians associated with a reduced risk of malpractice claims? METHODS Using data on nearly all admissions to acute care hospitals in Florida during 2000-09 linked to malpractice history of the attending physician, this study investigated whether physicians in seven specialties with higher average hospital charges in a year were less likely to face an allegation of malpractice in the following year, adjusting for patient characteristics, comorbidities, and diagnosis. To provide clinical context, the study focused on obstetrics, where the choice of caesarean deliveries are suggested to be influenced by defensive medicine, and whether obstetricians with higher adjusted caesarean rates in a year had fewer alleged malpractice incidents the following year. STUDY ANSWER AND LIMITATIONS The data included 24,637 physicians, 154,725 physician years, and 18,352,391 hospital admissions; 4342 malpractice claims were made against physicians (2.8% per physician year). Across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim. For example, among internists, the probability of experiencing an alleged malpractice incident in the following year ranged from 1.5% (95% confidence interval 1.2% to 1.7%) in the bottom spending fifth ($19,725 (£12,800; €17,400) per hospital admission) to 0.3% (0.2% to 0.5%) in the top fifth ($39,379 per hospital admission). In six of the specialties, a greater use of resources was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. A principal limitation of this study is that information on illness severity was lacking. It is also uncertain whether higher spending is defensively motivated. WHAT THIS STUDY ADDS Within specialty and after adjustment for patient characteristics, higher resource use by physicians is associated with fewer malpractice claims. FUNDING, COMPETING INTERESTS, DATA SHARING This study was supported by the Office of the Director, National Institutes of Health (grant 1DP5OD017897-01 to ABJ) and National Institute of Aging (R37 AG036791 to JB). The authors have no competing interests or additional data to share.
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Affiliation(s)
- Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA; and Massachusetts General Hospital, Boston, MA, USA National Bureau of Economic Research, Cambridge, MA, USA
| | - Lena Schoemaker
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Jay Bhattacharya
- National Bureau of Economic Research, Cambridge, MA, USA Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Seth A Seabury
- National Bureau of Economic Research, Cambridge, MA, USA Department of Emergency Medicine and Leonard D Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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Turillazzi E, Neri M. Informed consent and Italian physicians: change course or abandon ship--from formal authorization to a culture of sharing. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2015; 18:449-453. [PMID: 25841363 PMCID: PMC4484751 DOI: 10.1007/s11019-015-9637-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In Italy in recent years, an exponential increase in the frequency of medical malpractice claims relating to the issue of informed consent has substantially altered not only medical ethics, but medical practice as well. Total or partial lack of consent has become the cornerstone of many malpractice lawsuits, and continues to be one of the primary cudgels against defendant physicians in Italian courtrooms. Physicians have responded to the rising number of claims with an increase in 'defensive medicine' and a prevailing preoccupation with the purely formal aspects of consent. The result is a plethora of consent forms, believed to be a guarantee of 'informed consent', as well as a growing reliance on informed consent as a shield against judicial action brought by the patient. Physicians 'inform' patients without really sharing information, often delegating the task of communication to other professionals who are not doctors. Italian judges always condemn the physician when information to the patient has been inadequate, thus leading insurance companies to consider the lack of valid informed consent as the total responsibility of the physician and/or the hospital. It is necessary to change tack, to remove this idea of consent which permeates the defensive culture of medical practice. Italian physicians need to be trained, first of all, to become aware that information and consent are two distinct processes, albeit closely connected. Valid communication (in which there is information and consent) demands a higher level of professionalism from physicians.
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Ortashi O, Virdee J, Hassan R, Mutrynowski T, Abu-Zidan F. The practice of defensive medicine among hospital doctors in the United Kingdom. BMC Med Ethics 2013; 14:42. [PMID: 24168064 PMCID: PMC3874772 DOI: 10.1186/1472-6939-14-42] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 10/22/2013] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Defensive medicine is defined as a doctor's deviation from standard practice to reduce or prevent complaints or criticism. The objectives of this study were to assess the prevalence of the practice of defensive medicine in the UK among hospital doctors and the factors affecting it. METHODS A quantitative study was designed, with a detailed seventeen point questionnaire. Defensive medicine practice was assessed and tested against four factors age, gender, specialty and grade. Three hundred hospital doctors from three UK hospitals received the questionnaire. RESULTS Two hundred and four (68%) out of 300 hospital doctors responded to the survey. Seventy eight percent reported practicing one form or another of defensive medicine. Ordering unnecessary tests is the commonest form of defensive medicine reported by 59% of the respondents. This is followed by unnecessary referral to other specialties (55%). While only 9% of the sampled doctors would refuse to treat high risk patients, double this number would avoid high risks procedures all together (21%). A linear regression module has shown that only senior grade was associated with less practice of defensive medicine. CONCLUSION Defensive medical practice is common among the doctors who responded to the survey. Senior grade is associated with less practice of defensive medicine.
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Affiliation(s)
- Osman Ortashi
- Department of Gynaecology, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
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Picarelli A, Di Tola M, Borghini R, Isonne C, Saponara A, Marino M, Casale R, Tiberti A, Pica R, Donato G, Frieri G, Corazziari E. Colonic Involvement in Celiac Disease and Possible Implications of the Sigmoid Mucosa Organ Culture in its Diagnosis. J Clin Immunol 2013; 33:1250-6. [DOI: 10.1007/s10875-013-9920-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/24/2013] [Indexed: 12/12/2022]
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Gomez V, Raimondo M. "Primum Non Nocere": are we getting carried away? Dig Liver Dis 2013; 45:462-3. [PMID: 23643566 DOI: 10.1016/j.dld.2013.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 03/17/2013] [Indexed: 12/11/2022]
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